MEDICARE: MARY DUDEVOIR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	1212	CO

General Provider Information

NPI Number	:	1497142095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY DUDEVOIR

Provider Business Mailing Address
First Line	:	12892 ROCKBRIDGE CIR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-3743
Country	:	US
Telephone Number	:	845-926-8707
Fax Number	:

Provider Business Practice Location Address
First Line	:	12892 ROCKBRIDGE CIR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-3743
Country	:	US
Telephone Number	:	845-926-8707
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2015
Last Update Date	:	04/21/2015

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